Three-month cardiac outcomes of survivors of COVID-19 presenting to a district general hospital in West Hertfordshire, UK

Background

COVID-19 is novel entity associated with significant morbidity and mortality. Most patients recover completely, however, a proportion describe persistent symptoms consistent with cardiopulmonary disturbance. The long-term cardiac and respiratory outcomes of COVID-19 are not known.

Purpose

The aim of this study was to undertake a comprehensive cardiopulmonary assessment of survivors of COVID-19 with post recovery symptoms. The cardiac findings are presented here.

Methods

Survivors of COVID-19 presenting to a general hospital in West Hertfordshire between 18 March 2020 and 15 May 2020, were reviewed at 3 months using a structured prespecified protocol. Patients with persistent symptoms and those admitted to the intensive care unit (ICU) were invited to attend a clinical assessment comprising an electrocardiogram (ECG), echocardiography, chest x-ray (CXR) and pulmonary function tests. At follow up, patients were categorised according to disease course: 1) monitored via a community based virtual hospital, 2) admitted for supplemental oxygen, 3) requiring non-invasive ventilation and 4) ICU admission.

Results

448 eligible patients were evaluated by telephone. 11 patients admitted to ICU and 147 patients with persistent symptoms were invited for further assessment. At presentation, hospitalised patients were older, had higher levels of obesity and increased rates of hypertension than those managed virtually (p<0.05). Among hospitalised patients, the degree of pulmonary infiltration on CXR was higher, ROX index for intubation lower, eGFR lower, C-reactive protein levels higher and lymphocyte counts lower, compared to those managed virtually (p<0.05). The prevalence of known respiratory conditions was higher among patients admitted to hospital, with a trend towards statistical significance (p=0.051). There were no differences in the prevalence of known cardiac disorders and other co-morbidities amongst both patient groups (table 1).

At follow up, CXR appearances were improved and similar among patients monitored virtually, those admitted for supplemental oxygen, those requiring non-invasive ventilation and those treated on ICU. There were no differences in heart rhythm and ECG parameters in the four patient groups. Left ventricular systolic and diastolic dimensions, Simpson's biplane ejection fraction, left atrial volume and left ventricular filling pressures were similar in all four patient groups. There were no differences in right ventricular dimensions, right ventricular fractional area change, tricuspid annular plane systolic excursion and pulmonary artery systolic pressures among patients irrespective of disease severity (table 2).

Conclusions

At 3 months, we identified no differences in ECG indices and echocardiographic parameters of left and right ventricular function among survivors of COVID-19, independent of disease course. The findings of this study argue against significant cardiac sequalae following COVID-19 infection.

Funding Acknowledgement

Type of funding sources: None.

Lung cancer tissue diagnosis in poor lung function: addressing the ongoing percutaneous lung biopsy FEV1 paradox using Heimlich valve

Many centres continue to decline percutaneous lung biopsy (PLB) in patients with poor lung function (particularly FEV1 <1 L) due to the theoretically increased risk of pneumothorax. This practice limits access to novel lung cancer therapies and minimally invasive surgical techniques. Our retrospective single-centre analysis of 212 patients undergoing PLB, all performed prospectively and blinded to lung function, demonstrates that using ambulatory Heimlich valve chest drain (HVCD) to treat significant postbiopsy pneumothorax facilitates safe, diagnostic, early discharge lung biopsy irrespective of lung function with neither FEV1 <1 L nor transfer coefficient for carbon monoxide (TLCO) <40% predicted shown to be independent predictors of HVCD insertion or pneumothorax outcomes. Incorporating ambulatory HVCD into standard PLB practice thereby elegantly bridges the gap that currently exists between tissue diagnosis in patients with poor lung function and the advanced therapeutic options available for this cohort.

Ambulatory percutaneous lung biopsy with early discharge and Heimlich valve management of iatrogenic pneumothorax: more for less

A prospective study of 489 consecutive outpatient image-guided percutaneous lung biopsies was conducted to determine whether early discharge, incorporating ambulatory Heimlich valve drain, is potentially advantageous to the National Health Service. Patients were discharged at 30 or 60 min, with significant pneumothoraces treated using Heimlich valve. 485 (99.2%) patients were successfully discharged early, 402 at 30 min. 87 (17.8%) patients developed pneumothorax: 52 required Heimlich valve; 5 proceeded to biopsy with Heimlich valve in situ. All drains were removed within 48 h, 38/52 (73.1%) at 24 h. Our results provide evidence for a paradigm shift in UK practice: early discharge lung biopsy, facilitated by ambulatory Heimlich valve, is safe with significant clinical and economic benefits.

Circulating type I collagen degradation products: a new serum marker for clinical severity in patients with scleroderma?

Systemic sclerosis (SSc; scleroderma) results in the excessive deposition of extracellular matrix components in affected organs. This is partly due to enhanced synthesis; however, the role of degradative processes in this disease is still poorly understood. Sera of 32 patients with SSc (22 with the diffuse, 10 with the limited form) and of six patients with morphoea were assessed using radioimmunoassays for the cross-linked carboxy terminal telopeptide of type I collagen (ICTP) and for the amino terminal propeptide of type I procollagen (PINP) reflecting type I collagen degradation and synthesis, respectively. In 27 of the 32 patients with SSc, the concentration of ICTP was above the upper limit of the normal value (4.6 micrograms/L) and the mean level was clearly elevated at 7.92 micrograms/L. The ICTP concentration correlated with the skin score measuring the extent of the lesions, whereas no such correlation was found for PINP. The ICTP antigen in serum, studied by immunoblotting, had a molecular weight of about twice that of the trypsin-generated fragment isolated from human bone collagen. The mean concentration of serum PINP was 43.9 micrograms/L and no patient exceeded the upper limit of the normal range (80 micrograms/L). We report here for the first time that the concentration of the type I collagen degradation product ICTP in serum shows a close correlation with the extent of skin fibrosis in patients with SSc. We conclude that the increased deposition of type I collagen in this disease is accompanied by an increased turnover of this molecule, indicating a more complex derangement of synthetic and degradative processes than previously acknowledged.

Increased levels of endothelin-1 and differential endothelin type A and B receptor expression in scleroderma-associated fibrotic lung disease

In addition to their vasoactive action, endothelins are potent peptides in the regulation of both cell proliferation and the turnover of extracellular matrix. Using immunohistochemical, autoradiographic, and molecular analyses, we have studied the localization and expression of endothelin-1 and endothelin A (ETA) and B (ETB) receptors in scleroderma-associated fibrotic lung disease. Increased ET-1 immunoreactivity was found in sclerotic tissue compared with control and was associated with the vasculature, pulmonary interstitium, and bronchial and alveolar epithelium. Microautoradiographic analysis after 125I-labeled ET-1 binding showed a two- to threefold increase in the expression of total ET-1 receptors in scleroderma lung tissue localized to the alveolar epithelium and the pulmonary interstitium which was composed of mainly fibroblastic cells with macrophages and some microvessels. RNAse protection assay revealed significantly reduced ETA receptor and slightly raised ETB message levels in systemic sclerosis lung. Surface expression of functional ET receptors was examined by targeted receptor blocking using mixed and receptor-subtype-selective ligands. A consistent decrease in ETA receptor binding sites was noted primarily within the interstitium and vasculature, in contrast to a slight increase in ETB receptors. Elevated ET-1 and the cell-specific pattern of endothelin receptor expression suggest that the endothelins may represent important mediators that influence the pathology of scleroderma-associated lung disease and other fibrotic conditions.

Childhood-onset scleroderma: is it different from adult-onset disease

OBJECTIVE

To distinguish childhood-onset scleroderma from adult-onset disease.

METHODS

The clinical and serologic features of 58 patients with childhood-onset scleroderma (11 patients with diffuse cutaneous systemic sclerosis [SSc], 16 with linear SSc, 14 with linear morphea, and 17 with morphea) were examined in the largest cohort of such patients studied to date. These parameters were compared with data obtained from patients with adult-onset disease.

RESULTS

Childhood-onset scleroderma resembled adult-onset disease with regard to the heterogeneity of clinical expression and subsets of disease, but it also differed from adult-onset disease in a number of clinical and laboratory parameters. The predominant childhood-onset disease presentation was the localized form of the disease, with limited and diffuse SSc being less notable. There was a significant association of trauma with childhood-onset scleroderma (P < 0.0001), which was not noted in adult-onset disease. Furthermore, in contrast to adult disease, patients with childhood-onset disease had normal levels of parameters of vascular activation (von Willebrand factor, angiotensin-converting enzyme, E-selectin, and endothelin-1), T cell activation (soluble interleukin-2 receptors), and collagen synthesis (carboxy-terminal type I and amino-terminal type III), a notable lack of anticentromere antibodies, and abnormal coagulation indices.

CONCLUSION

A number of features distinguish childhood-onset scleroderma from adult-onset disease.

Scleroderma-derived human fibroblasts retain abnormal phenotypic and functional characteristics following retroviral transduction with the SV40 tsT antigen

In this study an amphotropic retrovirus has been used to efficiently transduce normal human (NF) and scleroderma (systemic sclerosis; SSc) dermal fibroblasts (SScF) with a sequence encoding a temperature-sensitive mutant of the SV40 large T antigen (tsA58-U19). From the primary outgrowths of skin explants, cultures were generated whose growth was stringently temperature-dependent. When grown at a low, permissive temperature (35 degrees C), both normal and SSc-transduced cells continuously divided with similar doubling times, whereas at a high, nonpermissive temperature (39.5 degrees C), division of both the NF and SScF cells was rapidly arrested. These cells have been passaged more than 50 times, have the typical morphological appearance of fibroblasts, and have retained an anchorage-dependent phenotype. The transduced normal cells (tsT-NF) synthesized the matrix molecules collagen and fibronectin and expressed phenotypic antigens characteristic of their nontransduced counterparts, including MHC Class I, VLA beta 1 (CD29), Hermes 1 (CD44), VLA-4 alpha (CD49d), ICAM-1 (CD54) and LFA-3 (CD58) and the cell surface ectoenzymes neutral endopeptidase (CD10), aminopeptidase N (CD13), and dipeptidyl peptidase IV (CD26). Analysis of the transduced SSc fibroblasts (tsT-SScF) showed that these cells exhibited certain major features of the SSc pathology, notably the abnormally high synthesis of type I collagen, increased expression of ICAM-1, and depressed levels of CD26. Moreover, these phenotypic characteristics were retained even after prolonged culture in vitro. The tsT-SScF cells also retained their responsiveness to cytokines, since interferon-gamma (IFN-gamma) and tumor necrosis factor-alpha (TNF-alpha) both produced a marked increase in ICAM-1 expression. Our findings show that infection of SScF with the SV40 tsT antigen extends the life span of these cells and does not ablate their abnormal phenotypic and functional characteristics.

Increased susceptibility to oxidation of low-density lipoproteins isolated from patients with systemic sclerosis

OBJECTIVE

To examine the resistance to oxidation of low-density lipoproteins (LDL) from patients with systemic sclerosis (SSc) and primary Raynaud's phenomenon (RP) compared with healthy controls.

METHODS

Plasma LDL were isolated from patients with diffuse cutaneous and limited cutaneous SSc (dcSSc and lcSSc, respectively), patients with primary RP, and healthy control subjects. The lipoproteins were assessed for their resistance to oxidation in the presence of cupric ions, using spectrophotometric assays.

RESULTS

LDL from patients with dcSSc and lcSSc were more susceptible to oxidation than were those from healthy control subjects or patients with RP.

CONCLUSION

Our findings suggest that free radicals may play a role in the pathology of SSc.

HLA type as a predictor of mixed connective tissue disease differentiation. Ten-year clinical and immunogenetic followup of 46 patients

OBJECTIVE

To determine any clinical or genetic markers of differentiation and outcome in a previously described cohort of 46 patients with mixed connective tissue disease (MCTD).

METHODS

Patients were clinically evaluated, chart notes reviewed, and HLA subtyping and immunology profiles performed where possible. Eleven had died and 7 were lost to followup.

RESULTS

MCTD had differentiated into systemic lupus erythematosus in 12 patients and into systemic sclerosis in 13. The latter was associated with HLA-DR5 (P = 0.038), and nondifferentiation was associated with HLA-DR2 or DR4 (P = 0.007). Three HLA-DR4 positive patients had MCTD that evolved into rheumatoid arthritis. Erosive and/or deforming arthritis was associated with HLA-DR1 or DR4 (P = 0.015). HLA-DR3 was associated with interstitial lung fibrosis (P = 0.044) and keratoconjunctivitis sicca (0.001 < P < 0.01). Severe Raynaud's phenomenon predicted higher mortality (0.01 < P < 0.05).

CONCLUSION

We suggest that MCTD is, for most patients, an intermediate stage in a genetically determined progression to a recognized connective tissue disease. Those whose disease remains undifferentiated might be considered a distinct subset.

Expression of ectopeptidases in scleroderma

OBJECTIVES

To examine the expression and concentrations of three ectopeptidases likely to be involved in regulating the functional levels of adhesion molecules and the turnover of connective tissue components, in patients with scleroderma (systemic sclerosis) (SSc) and in normal individuals.

METHODS

Monoclonal antibodies against these antigens were used for immunoperoxidase staining of cryostat skin sections and for flow cytometric (fluorescence activated cell sorter) analysis of cultured dermal fibroblasts grown from SSc patients and normal controls.

RESULTS

Although neutral endopeptidase-24.11 (NEP) (CD10) was not detected in either SSc or normal skin, aminopeptidase N (APN) (CD13) and dipeptidyl peptidase IV (DPPIV) (CD26) were both readily visualised. However, DPPIV appeared to be present in smaller concentrations in the SSc biopsy specimens. Moreover, while fibroblasts grown in vitro from both SSc and normal skin also had similar concentrations of APN, the expression of DPPIV in the cultured SSc cells was found to be very much less than that present in the normal fibroblasts. It is noteworthy that NEP, which was not detected in the tissue sections, was nevertheless readily detected in fibroblasts in culture.

CONCLUSIONS

These results show that a number of cell surface proteases are expressed by dermal fibroblasts both in vivo and in vitro, and it is suggested that the marked downregulation of DPPIV in SSc could be at least partly responsible for the increased concentrations of adhesion molecules and matrix proteins associated with the molecular pathology of this disease.

Expression and shedding of intercellular adhesion molecule 1 and lymphocyte function-associated antigen 3 by normal and scleroderma fibroblasts. Effects of interferon-gamma, tumor necrosis factor alpha, and estrogen

OBJECTIVE

To examine intercellular adhesion molecule 1 (ICAM-1) and lymphocyte function-associated antigen 3 (LFA-3) in cultures of normal and systemic sclerosis (SSc) dermal fibroblasts.

METHODS

The surface and soluble forms of ICAM-1 and LFA-3 were measured by flow cytometry and capture enzyme-linked immunosorbent assay, respectively.

RESULTS

Surface ICAM-1 was significantly higher on SSc fibroblasts compared with normal controls. Beta-estradiol did not directly enhance ICAM-1 or LFA-3 expression in either normal or SSc cells, but significantly augmented the cytokine-induced increase in ICAM-1. Soluble ICAM-1 (sICAM-1) and sLFA-3 were detected in fibroblast cultures. While no difference was found in the level of sLFA-3, the shedding of sICAM-1 was significantly increased (P < 0.001) in cells from SSc patients.

CONCLUSION

SSc fibroblasts express intrinsically elevated levels of surface ICAM-1 and release higher levels of sICAM-1 in vitro. Increased expression of ICAM-1 by interferon-gamma and tumor necrosis factor alpha alone, and the further induction in combination with beta-estradiol may underlie an aspect of fibroblast dysfunction in SSc and the female predisposition to the disease.

Circulating endothelin-1 levels in systemic sclerosis subsets--a marker of fibrosis or vascular dysfunction?

OBJECTIVE

To investigate the circulating levels of endothelin-1 (ET-1) in serum (sET-1) in patients with pulmonary disease [pulmonary fibrosis (PF) and pulmonary hypertension (PHT)], and renal involvement [hypertensive renal crisis (HRC)] in the 2 major subsets of systemic sclerosis (SSc) in order to determine the significance of sET-1 levels in relation to specific organ involvement or to the underlying pathogenic mechanisms of vascular damage and fibrosis.

METHODS

In addition to the measurement of ET-1 in serum using a competitive radioimmunoassay, the circulating levels of angiotensin converting enzyme (ACE) and plasma von Willebrand factor (vWF) were measured as markers of endothelial damage in the various disease groups.

RESULTS

Levels of sET-1 were significantly increased in 64 patients with diffuse systemic sclerosis (dSSc) and 17 patients with primary Raynaud's phenomenon (RP) compared with 22 healthy individuals. sET-1 levels were equally elevated in diffuse cutaneous disease (dcSSc) with only fibrotic dermal or lung pathology compared with patients with additional PHT or HRC crisis. These observations were in marked contrast to the sET-1 levels seen in patients with the limited cutaneous form of SSc (lcSSc) where only patients with lcSSc with hypertensive lung or renal disease had significantly higher levels of sET-1 than comparable lcSSc patients with only fibrotic dermal and lung disease. sET-1 levels were additionally found to correlate with plasma vWF, skin fibrosis (skin score) and duration of disease in patients with SSc.

CONCLUSION

The presence of significantly raised sET-1 levels in patients with dcSSc with widespread fibrosis and patients with lcSSc with hypertensive disease and the relationship seen between sET-1 levels and markers of fibrosis and vascular damage suggest that ET-1 may be important in the pathogenesis of both the fibrotic and vascular manifestations in SSc.

Localization of endothelin-1 and its binding sites in scleroderma skin

OBJECTIVE

Endothelin-1 (ET-1) has been implicated in the pathogenesis of systemic sclerosis (SSc) as it is both a potent vasoconstrictor and fibroblast mitogen and is raised in the circulation of patients with SSc and primary Raynaud's phenomenon.

METHODS

We examined the localization and level of expression of ET-1 and its putative receptors in clinically "uninvolved" (i.e., prescleroderma skin) and involved skin from patients with diffuse cutaneous systemic sclerosis (dcSSc), using the alkaline phosphatase antialkaline phosphatase technique while ET-1 binding sites were examined using in vitro autoradiography.

RESULTS

There was an increase in dermal ET-1 staining in clinically uninvolved and involved skin from patients with early active dcSSc compared with late stage fibrotic SSc skin and normal skin from healthy volunteers. Increased ET-1 staining was associated predominantly with the superficial vessels in the SSc skin sections. In addition, there was a significant increase in [125I]ET-1 binding to superficial vessels and the dermal/epidermal junction in SSc skin compared with the binding to similar structures in normal tissue. There was no change in [125I]ET-1 binding to the deep dermal vessels in both SSc and normal skin. This increase in [125I]ET-1 binding in SSc skin was not maintained with increasing tissue fibrosis.

CONCLUSION

The presence of increased ET-1 levels as well as its binding sites in both the prescleroderma and involved skin of patients with dcSSc compared to controls suggests that ET-1 may play a role in the pathology of dermal fibrosis and vasoconstriction in SSc.

Immunocytochemical localization and serologic detection of transforming growth factor beta 1. Association with type I procollagen and inflammatory cell markers in diffuse and limited systemic sclerosis, morphea, and Raynaud's phenomenon

OBJECTIVE

To determine the presence of transforming growth factor beta 1 (TGF beta 1) and inflammatory cell markers (HLA-DR and Factor XIIIa) and to compare these with the presence of type I procollagen, in clinically uninvolved and involved skin from patients with different subsets of systemic sclerosis (SSc), and to analyze circulating levels of TGF beta 1 in SSc patients.

METHODS

TGF beta 1, HLA-DR, Factor XIIIa, and type I procollagen were detected in skin biopsy sections using a biotin-streptavidin-peroxidase system. Levels of circulating TGF beta 1 were measured using a capture enzyme-linked immunosorbent assay technique.

RESULTS

Patients with active diffuse cutaneous SSc (dcSSc) showed minimal TGF beta 1 but significant type I procollagen staining in involved skin, while the clinically uninvolved skin of these patients showed moderate extracellular and intra-epidermal TGF beta 1 immunoreactivity. Patients with limited cutaneous SSc (lcSSc) showed elevated TGF beta 1 staining in both involved and uninvolved skin, as well as procollagen staining. Significant TGF beta 1 reactivity, HLA-DR and Factor XIIIa immunoreactivity, numerous inflammatory cells, and procollagen staining were seen in specimens from patients with morphea. Sequential biopsies suggested the presence of cytokine activity at the earliest stages of disease, which was not maintained with progression of sclerosis. Among the disease groups studied, elevated levels of circulating TGF beta 1 were seen only in patients with morphea.

CONCLUSION

The pattern of TGF beta 1 staining in dermal sections from patients with dcSSc, lcSSc, and morphea suggests that this cytokine is important in the pathogenesis of scleroderma. Furthermore, the presence of TGF beta 1 prior to the onset of fibrosis indicates an early involvement of this growth factor, possibly in the inflammatory stage of the disease.

Alpha interferon-2a (Roferon-A) in the treatment of diffuse cutaneous systemic sclerosis: a pilot study. UK Systemic Sclerosis Study Group

Intramuscular alpha-interferon improved or stabilized skin score in 10/14 (71%) patients with diffuse cutaneous systemic sclerosis. In 64% of patients, their treating physicians rated it as having stabilized or improved the disease. However, it had no significant effect on grip strength, digital contractures, respiratory function or visceral involvement. Type I collagen synthesis was significantly reduced in fibroblasts cultured from clinically 'uninvolved' skin but not in those from lesional skin. Amino-terminal procollagen III peptides in the interferon treated group were not significantly reduced after 6 months of therapy but showed a trend towards stabilization and reduction compared to disease matched controls on no therapy.